Form W-2AS American Samoa Wage and Tax Statement (Info Copy Only)

1. Attention:
This form is provided for informational purposes only. Copy A appears in red, similar
to the official IRS form. Do not file copy A downloaded from this website with the
SSA. The official printed version of this IRS form is scannable, but the online version
of it, printed from this website, is not. A penalty of $50 per information return may be
imposed for filing forms that cannot be scanned.
To order official IRS forms, call 1-800-TAX-FORM (1-800-829-3676) or Order
Information Returns and Employer Returns Online, and we’ll mail you the scannable
forms and other products.
You may file Forms W-2 and W-3 electronically on the SSA’s website at
Employer Reporting Instructions & Information. You can create fill-in versions of
Forms W-2 and W-3 for filing with SSA. You may also print out copies for filing
with state or local governments, distribution to your employees, and for your
records.
See IRS Publications 1141, 1167, 1179 and other IRS resources for information
about printing these tax forms.

2. a Employee’s social security number For Official Use Only
22222 Void
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Samoa income tax withheld
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 8
d Control number 9 10
e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See the separate instructions
C
o
d
e
Statutory Retirement Third-party
13 12b
employee plan sick pay C
o
d
e
12c
14 Other
C
o
d
e
12d
C
o
f Employee’s address and ZIP code d
e
American Samoa
W-2AS 2008
Department of the Treasury—Internal Revenue Service
Wage and Tax Statement For Privacy Act and Paperwork Reduction Act
Form
Notice, see the separate instructions.
Copy A For Social Security Administration—Send this entire page with Copy A of
Form W-3SS to the Social Security Administration; photocopies are not acceptable. Cat. No. 10140H
Do Not Cut, Fold, or Staple Forms on This Page — Do Not Cut, Fold, or Staple Forms on This Page

3. a Employee’s social security number
22222 Void
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Samoa income tax withheld
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 8
d Control number 9 10
e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a
C
o
d
e
Statutory Retirement Third-party
13 12b
employee plan sick pay C
o
d
e
12c
14 Other
C
o
d
e
12d
C
o
f Employee’s address and ZIP code d
e
American Samoa
W-2AS 2008
Department of the Treasury—Internal Revenue Service
Wage and Tax Statement
Form
Copy 1—For American Samoa Treasurer

4. a Employee’s social security number
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Samoa income tax withheld
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 8
d Control number 9 10
e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
d
e
Statutory Retirement Third-party
13 12b
employee plan sick pay C
o
d
e
12c
14 Other
C
o
d
e
12d
C
o
f Employee’s address and ZIP code d
e
American Samoa
W-2AS 2008
Department of the Treasury—Internal Revenue Service
Wage and Tax Statement
Form
This information is being furnished to the Tax
Copy B—To Be Filed With Employee’s American Samoa Tax Return Department, American Samoa Government.

5. Credit for excess social security tax. If you had more than one
Notice to Employee
employer in 2008 and more than $6,324.00 in social security tax
File Copy B of this form with your 2008 American Samoa income was withheld, you may have the excess refunded by filing Form
tax return. Keep Copy C for your records. If your name, social 843, Claim for Refund and Request for Abatement, with the
security number (SSN), or address is incorrect, correct Copies B Department of the Treasury, Internal Revenue Service Center,
and C and ask the employer to correct your employment record. Austin, TX 73301-0215, USA. If you must file Form 1040 with the
Be sure to ask your employer to file Form W-2c, Corrected Wage United States, claim the excess tax as a credit on Form 1040.
and Tax Statement, with the Social Security Administration (SSA) to
Note. Keep Copy C of Form W-2AS for at least 3 years after the
correct any name, amount, or SSN error reported to the SSA.
due date for filing your income tax return. However, to help protect
If you expect to owe self-employment tax of $1,000 or more for your social security benefits, keep Copy C until you begin
2009, you may have to make estimated tax payments to the U.S. receiving social security benefits just in case there is a question
Internal Revenue Service. Use Form 1040-ES, Estimated Tax for about your work record and/or earnings in a particular year. Review
Individuals. the information shown on your annual (for workers over 25) Social
Security Statement.
Refund. Even if you do not have to file a tax return, you should file
to get a refund if box 2 shows Samoa income tax withheld. (Also see the Instructions for Employee on the back of Copy C.)

6. a Employee’s social security number
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Samoa income tax withheld
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 8
d Control number 9 10
e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
d
e
Statutory Retirement Third-party
13 12b
employee plan sick pay C
o
d
e
12c
14 Other
C
o
d
e
12d
C
o
f Employee’s address and ZIP code d
e
American Samoa
W-2AS 2008
Department of the Treasury—Internal Revenue Service
Wage and Tax Statement
Form
This information is being furnished to the Tax
Department, American Samoa Government.
Copy C—For EMPLOYEE’S RECORDS (See Notice to Employee on the back of Copy B.)

7. H—Elective deferrals to a section 501(c)(18)(D) tax-exempt organization plan. (You may
Instructions for Employee be able to deduct.)
(Also see Notice to Employee, on the back of Copy B.) J—Nontaxable sick pay (information only, not included in boxes 1, 3, or 5).
Box 11. This amount is (a) reported in box 1 if it is a distribution from a nonqualified M—Uncollected social security tax on taxable cost of group-term life insurance over
deferred compensation or nongovernmental section 457(b) plan, or (b) included in box $50,000 (former employees only). Report on U.S. Form 1040.
3 and/or 5 if it is a prior year deferral under a nonqualified or section 457(b) plan that
N—Uncollected Medicare tax on taxable cost of group-term life insurance over
became taxable for social security and Medicare taxes this year because there is no
$50,000 (former employees only). Report on U.S. Form 1040.
longer a substantial risk of forfeiture of your right to the deferred amount.
P—Excludable moving expense reimbursements paid directly to employee (not
Box 12. The following list explains the codes shown in box 12. You may need this
included in boxes 1, 3, or 5).
information to complete your tax return. Elective deferrals (codes D, E, F, and S) and
Q—Nontaxable Combat Pay. See your tax return instructions for details on reporting
designated Roth contributions (codes AA and BB) under all plans are generally limited
this amount.
to a total of $15,500 ($10,500 if you only have SIMPLE plans; $18,500 for section
403(b) plans if you qualify for the 15-year rule explained in Pub. 571). Deferrals under R—Employer contributions to your Archer (MSA). Report on Form 8853, Archer MSAs
code G are limited to $15,500. Deferrals under code H are limited to $7,000. and Long-Term Care Insurance Contracts.
However, if you were at least age 50 in 2008, your employer may have allowed an
S—Employee salary reduction contributions under a section 408(p) SIMPLE (not
additional deferral of up to $5,000 ($2,500 for section 401(k)(11) and 408(p) SIMPLE
included in box 1).
plans). This additional deferral amount is not subject to the overall limit on elective
deferrals. For code G, the limit on elective deferrals may be higher for the last 3 years T—Adoption benefits (not included in box 1).
before you reach retirement age. Contact your plan administrator for more information.
V—Income from exercise of nonstatutory stock option(s) (included in boxes 1, 3 (up to
Amounts in excess of the overall elective deferral limit must be included in income.
social security wage base), and 5).
See the “Wages, Salaries, Tips, etc.” line instructions for your tax return.
W—Employer contributions to your Health Savings Account. Report on Form 8889,
A—Uncollected social security tax on tips. Report on U.S Form 1040. Health Savings Accounts (HSAs).
B—Uncollected Medicare tax on tips. Report on U.S. Form 1040. Y—Deferrals under a section 409A nonqualified deferred compensation plan.
Z—Income under section 409A on a nonqualified deferred compensation plan. This
C—Taxable cost of group-term life insurance over $50,000 included in boxes 1, 3 (up
amount is also included in box 1. It is subject to an additional 20% tax plus interest.
to social security wage base), and 5.
See “Total Tax” in the instructions for your tax return.
D—Elective deferrals to a section 401(k) cash or deferred arrangement. Also includes
AA—Designated Roth contributions under a section 401(k) plan.
deferrals under a SIMPLE retirement account that is part of a section 401(k)
arrangement. BB—Designated Roth contributions under a section 403(b) plan.
E—Elective deferrals under a section 403(b) salary reduction agreement. Box 13. If the “Retirement plan” box is checked, special limits may apply to the
amount of traditional IRA contributions that you may deduct.
F—Elective deferrals under a section 408(k)(6) salary reduction SEP.
G—Elective deferrals and employer contributions (including nonelective deferrals) to a
section 457(b) deferred compensation plan.

8. a Employee’s social security number
Void
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Samoa income tax withheld
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
5 Medicare wages and tips 6 Medicare tax withheld
7 Social security tips 8
d Control number 9 10
e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See the separate instructions
C
o
d
e
Statutory Retirement Third-party
13 12b
employee plan sick pay C
o
d
e
12c
14 Other
C
o
d
e
12d
C
o
f Employee’s address and ZIP code d
e
American Samoa
W-2AS 2008
Department of the Treasury—Internal Revenue Service
Wage and Tax Statement
Form
For Privacy Act and Paperwork Reduction Act Notice,
see the separate instructions.
Copy D—For Employer

9. Form W-3SS, Transmittal of Wage and Tax Statements, with
Employers, Please Note— the Social Security Administration (SSA) at the same time.
Note. A minimum income tax of 2% must be withheld on Note. If you terminate your business, see the rules on
wages and other compensation. furnishing and filing Forms W-2AS and W-3SS under
Terminating a business in the separate instructions.
Who must file. File Form W-2AS for each employee from
whom American Samoa income tax or U.S. social security and When to file. By March 2, 2009, send Copy A of Forms W-2AS
Medicare taxes were withheld or required to be withheld and W-3SS to the SSA. However, if you file electronically, the
during 2008. due date is March 31, 2009. See the separate instructions.
Distribution of copies. By February 2, 2009, furnish Copies B Reporting electronically. If you file 250 or more Forms W-2AS,
and C to each person who was your employee during 2008. For you must file electronically. For information, visit SSA’s
anyone who stopped working for you before the end of 2008, Employer Reporting Instructions and Information webpage at
you may furnish Copies B and C to them any time after www.socialsecurity.gov/employer or contact your Employer
employment ends but by February 2, 2009. If the employee Services Liaison Officer (ESLO) at 510-970-8247.
asks for Form W-2AS, furnish the completed copies within 30
See the Instructions for Forms W-2AS, W-2GU, W-2VI, and
days of the request or within 30 days of the final wage
Form W-3SS for more information on how to complete Form
payment, whichever is later. You may also file Copy A and
W-2AS.